Free Segmental Vastus Lateralis Muscle Flap for Reconstruction of Recalcitrant Defects of the Cleft Hard Palate

Abstract

Introduction Large recalcitrant defects of the anterior palate due to clefting are difficult to close with local tissues. In some cases distant tissue transfer may be the only option. Free segmental vastus lateralis muscle with its long high-caliber pedicle and low donor-site morbidity may be a good option.

Patient/Method An 8-year-old girl with bilateral cleft lip and palate was evaluated for a defect in the anterior hard palate. She had four failed palate closures resulting in a 3.2 × 2.8 cm defect with severely scarred surrounding palatal tissues and severely hypernasal speech. A vastus lateralis muscle with a 7-cm pedicle was prepared. Only a 5 × 4 × 1 cm segment of muscle was harvested based on segmental motor innervations, thus sparing 90% of the remaining muscle. Vessels were anastomosed to the facial artery and vein through a facial tunnel. The flap was directed into the palatal defect via the right alveolar cleft and sutured in a fashion to prevent dehiscence and fistulization.

Results The surface of the flap mucosalized over an 8-week period. The defect was completely closed. The speech markedly improved. There was no donor-site morbidity.

Conclusion Free segmental vastus lateralis muscle offers easy harvest, a two-team approach, long pedicle length, a highly vascularized flap, and no functional loss.

Keywords

cleft palate - vastus lateralis muscle flap - hard palate reconstruction

• References

• 1 Yazar S, Wei FC, Cheng MH, Huang WC, Chuang DC, Lin CH. Safety and reliability of microsurgical free tissue transfers in paediatric head and neck reconstruction—a report of 72 cases. J Plast Reconstr Aesthet Surg 2008; 61: 767-771
• 2 Corrêa Chem R, Franciosi LF. Dorsalis pedis free flap to close extensive palate fistulae. Microsurgery 1983; 4: 35-39
• 3 MacLeod AM, Morrison WA, McCann JJ, Thistlethwaite S, Vanderkolk CA, Ryan AD. The free radial forearm flap with and without bone for closure of large palatal fistulae. Br J Plast Surg 1987; 40: 391-395
• 4 Chen HC, Ganos DL, Coessens BC, Kyutoku S, Noordhoff MS. Free forearm flap for closure of difficult oronasal fistulas in cleft palate patients. Plast Reconstr Surg 1992; 90: 757-762
• 5 Ninkovic M, Hubli EH, Schwabegger A, Anderl H. Free flap closure of recurrent palatal fistula in the cleft lip and palate patient. J Craniofac Surg 1997; 8: 491-495 , discussion 496
• 6 Turk AE, Chang J, Soroudi AE, Hui K, Lineaweaver WC. Free flap closure in complex congenital and acquired defects of the palate. Ann Plast Surg 2000; 45: 274-279
• 7 Eufinger H, Machtens E. Microsurgical tissue transfer for rehabilitation of the patient with cleft lip and palate. Cleft Palate Craniofac J 2002; 39: 560-567
• 8 Schwabegger AH, Hubli E, Rieger M, Gassner R, Schmidt A, Ninkovic M. Role of free-tissue transfer in the treatment of recalcitrant palatal fistulae among patients with cleft palates. Plast Reconstr Surg 2004; 113: 1131-1139
• 9 Tsuchiya S, Nakatsuka T, Sakuraba M. One-sided soft palatal reconstruction with an anterolateral thigh fasciocutaneous flap: report of two cases. Microsurgery 2011; 31: 150-154
• 10 Ozkan O, Ozkan O, Coskunfirat OK, Hadimioğlu N. Reconstruction of large palatal defects using the free anterolateral thigh flap. Ann Plast Surg 2011; 66: 618-622
• 11 Lutz BS, Wei FC, Chang SC, Yang KH, Chen IH. Donor site morbidity after suprafascial elevation of the radial forearm flap: a prospective study in 95 consecutive cases. Plast Reconstr Surg 1999; 103: 132-137
• 12 Hallock GG. Repair of an untreated cleft palate in an adult using a prefabricated radial forearm flap. Ann Plast Surg 1997; 38: 69-73
• 13 Krimmel M, Hoffmann J, Reinert S. Cleft palate fistula closure with a mucosal prelaminated lateral upper arm flap. Plast Reconstr Surg 2005; 116: 1870-1872
• 14 Zemann W, Kruse AL, Lüebbers HT, Jacobsen C, Metzler P, Obwegeser JA. Microvascular tissue transfer in cleft palate patients: advocacy of the prelaminated radial free forearm flap. J Craniofac Surg 2011; 22: 2006-2010
• 15 Wolff KD, Dienemann D, Hoffmeister B. Intraoral defect coverage with muscle flaps. J Oral Maxillofac Surg 1995; 53: 680-685 , discussion 686
• 16 Uğurlu K, Sacak B, Hüthüt I, Karsidag S, Sakiz D, Baş L. Reconstructing wide palatomaxillary defects using free flaps combining bare serratus anterior muscle fascia and scapular bone. J Oral Maxillofac Surg 2007; 65: 621-629
• 17 Schmelzeisen R, Schliephake H. Interdisciplinary microvascular reconstruction of maxillary, midfacial and skull base defects. J Craniomaxillofac Surg 1998; 26: 1-10
• 18 Christiano JG, Dorafshar AH, Rodriguez ED, Redett RJ, Redett RJ. Repair of recurrent cleft palate with free vastus lateralis muscle flap. Cleft Palate Craniofac J 2012; 49: 245-248
• 19 Elshal EE, Inokuchi T, Sekine J, Sano K. Experimental study of epithelialization of the muscle-only flap in the oral cavity. J Oral Maxillofac Surg 1997; 55: 1423-1430 , discussion 1431–1432
• 20 Kirschner RE, Cabiling DS, Slemp AE, Siddiqi F, LaRossa DD, Losee JE. Repair of oronasal fistulae with acellular dermal matrices. Plast Reconstr Surg 2006; 118: 1431-1440
• 21 Losee JE, Smith DM, Afifi AM , et al. A successful algorithm for limiting postoperative fistulae following palatal procedures in the patient with orofacial clefting. Plast Reconstr Surg 2008; 122: 544-554